Subject :- Application for the grant of Premises License for Cyber Café of
similar establishment providing of internet/internet
connectivity in a Public place.
Sir,

I/We the undersigned, Shri/Smt./Kum…………………………………………………Owner(s) of Cyber Cafe/Computer and /or Virtual Reality Game (as defined under section 2(9) of Mumbai Police Act-1951,
definition of place of public amusement), by name M/s…………..……………………………
would like to apply for grant of Premises License at the following address. The place belongs to
me/us take on rent is on lease/leave and license.

Details are as follows (if more than one applicant details of each applicant be provided):-

1. Full Name of Applicant :-……………………………………………..
(Extended initials)

2. Occupation :-……………………………………………..

3. Parentage :-……………………………………………..
(Fathers/Husband Name)

4. Age (Date of Birth) :-…………………………………………….

5. Nationality :-…………………………………………….

6. E-Mail Address of the Owner :-…………………………………………….

7. (a)Full Name and address of :-…………………………………………….
the Cyber Café/Establishment.

(b) Address of the Res. :-…………………………………………….

(c) Telephone No. :- …………………………………………...

(d) Fax No. :-……………………………………………

(e) E-mail Address of the :-…………………………………………….
Cyber Café.

(f) How many branches/outlets :-…………………………………………….
Existing, give details as per
this form.(use separate sheet
if required)

(g) Approximate area of the :-…………………………………………..
premises.

(h) Number of Terminal proposed :-…………………………………………..

8. (a) Whether premises are owned, :-…………………………………………….
Leased, rented or taken on leave
And license by applicant-owner?
(Specify)

(b) If on rental, lease or leave :-……………………………………………
and license period of tenancy/
lease/license.

9. (a) Whether any other name is used :-…………………………………………..
for the establishment.
If so, give details,

(b) Whether applied in the past :-…………………………………………..
for similar license, If so,
give details.

10. All telephone numbers at the Cyber :-…………………………………………..
Café with name and address of the
Telephone subscriber (Use separate
Sheet, if required)

11. Name and address of conductor :-…………………………………………..
or operator of Cyber Café if other
than applicant-owner.

12. Copies of documents bearing signature of the applicant which is to be attached
with this application (whichever is applicable according to each activity):-

1. Shops & Establishment License.
2. Copy of partnership deed, If partnership firm.
3. Rent Receipt, if the place is on rent/lease.
4. Bill of fire fighting equipment of current year.
5. Ownership documents, if the premises is owned by the applicant.
6. NOC from the landlord or Society, if the premises are residential.
7. Name, address and other details of manager / conductor, employees to be provided
separately on the firm’s letter head.
8. If establishment is a Company, copy of Memorandum of Articles.
9. Copy of the resolution under which applicant is authorized to sign and obtain the above
license from the Licensing Authority.
10. Copy of the current bill of payment made to ISP must be attached with the application.
11. No License shall have any claim of whatsoever nature against Government or Non-
Government authority, on the basis of the Cyber Café License issued by Police under
Cyber Café Licensing Rules.

If any other documents are required, the same will be submitted as soon as we are
informed. Copies of above documents are attached herewith.

It is requested that Premises License may kindly be granted. I will abide by the
conditions of the license.